AAA Physician:Referring Physician:

(Address)

First Name:

Sex:

Zip:Work Phone:

Language:

Ins. ID#: Group #:

State: Zip:

Telephone:

HAS ANY MEMBER OF YOUR FAMILY BEEN TREATED BY OUR PHYSICIAN(S) BEFORE? YES NO

IF THE ANSWER IS YES, PLEASE GIVE THE PATIENT'S NAME:

SPOUSE OR OTHER PARENT INFORMATIONName: Occupation:Employer: Telephone:

INSURED INFORMATIONPatient's Relationship to Insured (Spouse, Child, Dependent, Other):

If 'Other' Please Specify:Name of Insured:

Address:State: Zip:Telephone:

DOB: / /

RESPONSIBLE PARTY INFORMATIONIf the patient is a minor, the parent with whom the child resides is the responsible party:

Address:Responsible Party:

Employer: Emp Telephone:Occupation: Ins. Company:

Zip:State: Telephone:

PF-16 Rev. 10/19

DOB: / /

PATIENT MRN#:DATE:

Race:

Middle Initial:

Ethnicity:

County:Cell Phone:

PATIENT INFORMATION

Sex:

Last Name:

Birth Date:

Billing Address:

State:Home Phone:

Marital Status:Email:

Ins. Company:

Primary Care Dr:

Address:

Employer (if patient is a minor, this does not apply):

Telephone: Occupation:

VeteranStudent Smoker

Page 1

NEW PATIENT INFORMATION Date of Visit: Date of Birth:

Referring Doctor:

PROVIDER COMMENTS

(Do not write in this space)

How long have you had these problems?

How frequently do experience these problems?

I. ALLERGY HISTORY

1. I have the following symptoms (circle all that apply and star the most troublesome):

I was asked to see this pt in

consultation by

Dr. for .

nasal congestion

fatigue/irritability

post nasal drip

runny nose

sneezing

nasal polyps

nasal itch/rub

red eyes itchy eyes sinus infections

discolored drainage

headaches

bad breath

snoring

mouth breathing

nosebleeds

loss of taste/smell

2. Circle all symptom triggers (circle all that apply and star the most troublesome):

dust fall pollen

springtime pollen

cut grass/rake leaves dog

cat other animals

feathers

mold/mildew/ mustiness/dampness indoors outdoors weather changes smoke

strong odors temperature changes

time of day - am/pm

home

workplace

food

rain

Do your symptoms occur year-round or are they seasonal? Circle one or both. If seasonal,

list months symptoms occur:

No 3. Have you had sinus x-rays or CT Scan? Yes

II. RESPIRATORY HISTORY1. Circle any applicable symptoms.

cough

tightness cough from post nasal drip

symptoms with exercise

wheeze

shortness of breath

If you circled any of the above symptoms, complete questions 2-7

2. Do you wake up at night because of chest symptoms?times per week/month

3. Did you have problems with your breathing at birth? If yes, explain:

4. Breathing problem is triggered by:pollen

mold

foods

exercise

heartburn

weather change/rain

colds pets other

sinus infections cold weather

5. Circle any events attributable to your asthma:ER visits Hospitalization Intubation ICU admission Pneumonia

No Yes

PF-54 Rev. 10/19

6. Have you been on steroids or received a steroid shot for your asthma?If yes, how many times in the past 12 months?

7. Have you had a chest x-ray? Yes No Last x-ray:

Name:

Phone: Home ( )

Primary Care Doctor:

Pharmacy: __________________________ Phone #: Briefly describe your main reason for today’s visit:

Age:Phone: Work ( )

Nasal Symptoms/Causes

Yes No

Yes No

III. MEDICATIONSI take the following medications (include inhalers and nasal sprays):Name Dose Frequency used

1. Do you use a spacer with your inhaler?If yes, which type?

2. Do you own a home nebulizer?3. Do you own a peak �ow monitor?

If so, please list your best peak �ow rate

PROVIDER COMMENTS(Do not write in this space)

daily/often/rarelydaily/often/rarelydaily/often/rarely

Other medications:times a day/week/monthtimes a day/week/monthtimes a day/week/monthtimes a day/week/month

Did they help?

IV. PREVIOUS ALLERGY EVALUATIONHave you ever had allergy skin testing?If yes, whenWere you on allergen immunotherapy (allergy shots/drops)?If yes, whenV. ENVIRONMENTAL SURVEY - HOMEGeneral (Circle answers)1. Where do you live? House Apartment Trailer Condo Other2. How long have you lived there? Age of Dwelling:3. Pets (If yes, please specify):

Cat indoor outdoor bothDog indoor outdoor bothOther indoor outdoor both

4. Smokers/Vapers in the house?5. Is your home air conditioned? Yes No If yes, central or window?6. Do you keep your windows closed?7. Do you have a humidi�er? Yes No if yes, central or room?8. Do you have an electrostatic air �lter?9. Do you have moisture problems in your home?10. Do you have a basement? Yes No Is it damp?Bedroom1. Type of bed? Regular Waterbed/waveless Waterbed/wave

Yes No On pillow?2. Plastic encasement of mattress?3. Stuffed animals in bedroom? Yes No How many?4. Type of pillow: Feather Synthetic Cotton5. Do you have: Carpet Wood Vinyl �ooringVI. WORK/SCHOOL1. What is your occupation?2. A student? Yes No What grade are you in?3. What are your hobbies?4. Are your symptoms worse at work?5. Do you get better on vacation?6. How many days did you miss school or work in the past year?7. If child, is he/she in daycare?8. How many children in room?How long have you lived in Georgia? yearsWhere else have you lived?VII. FAMILY HISTORYDoes any member of your family have a history of:

Who: (father, mother, grandmother, etc.)AsthmaHay feverEczemaMigrainesRecurrent infections Cystic Fibrosis Insect Sting Reactions Other

PF-54 Rev. 10/19 Page 2

Yes No

Yes NoYes No

Yes No

Yes NoYes No

Yes No

Yes No

Yes No

Yes NoYes NoYes No

Yes No

Yes NoYes No

Yes No

MEDICAL PROBLEMSReview of Systems - Please circle any applicable problems

Date Reason

PROVIDER COMMENTS(Do not write in this space)

Constitutional: fever weight loss weight gain fatigue irritabilityEyes: swelling around eye discharge contact lens glaucoma cataractsHENT: hearing loss recurrent ear infections hayfever runny/itchy noseCardiac: palpitations chest pain high blood pressure heart disease

heart burn stomach pain diarrhea liver disease ulcerGI: nausea vomiting GU: pain of urination di�culty urinating frequent urination blood urinary infections prostate problemsMusculoskeletal: joint swelling bone pain frequent broken bones osteoporosis

Is child growing well? Yes NoSkin: eczema hives itching sores in mouth thrushNeurologic: headaches numbness seizures weakness migrainesPsychiatric: Allergies a�ecting the quality of life? Yes NoHematologic: anemia swollen glands bleeding HIV positiveOther Problems (circle all that apply)

Diabetes Thyroid diseaseTuberculosis Bowel diseaseAllergies Hayfever

Arthritis Cancer Asthma SURGERY/OPERATIONS Circle surgeries and give year Ear tubes Nasal/Sinus surgery Tonsillectomy/AdenoidectomyOther

Have you had chicken pox? Yes No VaccineSMOKING HISTORY Yes No How much? ______________ How often?For how many years? ______________ When did you stop?______________ VAPING HISTORY Yes No How much? ______________ How often?For how many years? ______________ When did you stop?______________ Have you had all your childhood immunizations? Do you get a flu shot every year? Have you had the Pneumovax vaccine? IX. MEDICATION ALLERGYMedication Reaction Date

VIII. GENERAL MEDICAL HISTORYHOSPITAL STAYS?

X. OTHER ALLERGIESDo you have eczema or hives? (circle)Have you ever had an allergic reaction to an insect sting?If yes, what happened?Are you allergic to any foods?Food Reaction Date

Have you ever had itching, sneezing or swelling after dental exam or GYN exam? Yes NoHave you ever had a reaction after using any of the following? (circle)

PF-54 Rev. 10/19 Page 3

balloons rubber products elastic bandages condom

Yes NoYes NoYes No

Yes NoYes No

Yes No

PF-54 Rev. 10/19 Page 4

Urticaria/Angioedema Section (Fill out only if you are being seen for Hives or Swelling) 1. How long have you had hives/swelling?2. Briefly describe the circumstances surrounding their onset:

2a. How often do you experience hives?

3. What medications are you taking for the hives/swelling?

4. How long does each individual hive last? <24 hours >24 hours5. Do they itch? Yes No6. Are they painful? Yes No7. Do you experience shortness of breath, wheeze, chest tightness, abdominal pain,

throat fullness, dizziness or diarrhea? (circle applicable symptoms)

8. Have you recently experienced fevers, chills, night sweats, swollen glands,swollen joints, weight gain or loss? (circle applicable symptoms)

PROVIDER COMMENTS

(Do not write in this space)

9. What “triggers” the hives/swelling (circle)

stress vibration exercise medications friction home food pressure

work heat sunlight cold

water other do not know

11.

12.

Do you have a family history of hives/angioedema?

Who?Have you ever had hives / angioedema in the past?

If yes, when & how long did they last?

Insect Section (Fill out only if you are being seen for Insect Allergy) 1. My reaction to an insect sting occurred on: Month Year 2. Please describe the location of sting and what happened at the time of the sting.

3. What caused the sting? Bee Wasp Yellow Jacket Hornet Ant Unknown4. The symptoms that occurred after the sting included (please circle)

swelling at the site trouble breathing

distant swelling (i.e. lips, tongue) trouble swallowing

hives vomiting

loss of consciousness dizziness

5. I received treatment at an emergency roomIf yes, which one?

Yes No

They gave me Benadryl Epinephrine Steroids IV fluids I don’t know

6. I have an EpiPen, Auvi-Q, or other epinephrine auto-injector.7. Have you ever been stung before?8. If yes, when and describe the reaction

Yes No

Yes No

Yes No

Yes No

Yes No

Atlanta Allergy & Asthma, PA - Financial Policy

In order to accommodate the needs and requests of as many patients as possible, Atlanta Allergy is contracted with numerous insurance companies. While we are pleased to be able to provide this service to you, it is not possible for our staff to keep track of all the individual requirements of each plan. Every plan has different stipulations regarding access to care and payment for services received. Within the same insurance company, benefits may differ depending upon what type of contract your employer negotiated with that carrier on your behalf.

Providing quality medical care for our patients is our primary concern.

We are happy to provide care for our patients, within their insurance contract guidelines, but we ask that our patients come prepared at the time of service to let us know what those guidelines are. With most of our contracts, Atlanta Allergy personnel are not permitted to interpret insurance benefits for the patient. We are expected and obligated to provide quality care to each insured person, but it is the insured person's responsibility to understand their benefits.

Should your insurance company require a specialist referral from your primary care physician before you can be seen by our physicians, it is your responsibility to obtain that referral prior to your appointment. You should bring the referral with you to your appointment. Our contracts with those insurance companies prohibit us from seeing you without a referral and billing them for the services. If you are seen without a referral, you must be prepared to pay for all services in full at the time they are rendered. If a referral is required and you are unsure as to how to obtain one, please let the staff know and we will be happy to provide assistance.

If you do not inform us of any special requirements in your insurance contract, such as referrals or pre-authorization for treatment, and we subsequently order services that are not covered, we will have no choice but to bill you directly for those charges. In the event that services are provided and your insurance coverage is not in effect on that day, or if your contract contains a pre-existing clause, your insurance carrier will likely deny payment for services received. Please remember that you, the patient, are ultimately responsible for payment on your account.

With your cooperation and help, you should be able to receive all of the insurance benefits offered to you, and we will be able to concentrate on caring for your medical needs.

Atlanta Allergy & Asthma Physicians and Staff

I HAVE READ AND UNDERSTAND THE OFFICE POLICY STATED ABOVE AND AGREE TO ACCEPT FINANCIAL RESPONSIBILITY AS DESCRIBED.

____________________________________________ ________ ______________________ (Patient and/or Insured) (Date)

_________________________________________________ (Print Name)

PF-98 Rev. 8/18

Acknowledgement of Receipt of Notice of Privacy Practices

Part 1:

Patient Name: _____________________________________________________________________________________

Address: __________________________________________City, State, Zip:

I have been given a copy of Atlanta Allergy & Asthma Notice of Privacy Practices (“Notice”), which describes how my health information is used and shared. I understand that Atlanta Allergy & Asthma (“the Practice”) has the right to change this Notice at any time. I may obtain a current copy by contacting the Practice Privacy Official, or by visiting the Practice website at www.atlantaallergy.com.

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

_____________________________________________________________ (Signature of Patient or Personal Representative) (Date)

Print Name & Title (e.g., Guardian, Health Care Power of Attorney):

Part 2:

Atlanta Allergy & Asthma clinical staff may need to communicate Protected Health Information (PHI), such as test or lab results, via phone. Please let us know what phone number you would like us to call and if we may leave a message:

Phone Number: ___________________________________________________

___ Yes, you may leave a message ___ No, please do not leave a message

I authorize the Practice to include the following person(s) in any communication regarding my PHI. This is a valid authorization until I revoke this in writing:

Name: __________________________________________________ Relationship: __________________________________

______________________________________________________ (Signature of Patient or Patient Representative)

-------------------------------------------------------------------------------------------------------------------------------------------------------------For Practice Use Only: Complete this section if you are unable to obtain signature. If the Patient or personal rep is unable or unwilling to sign the Privacy Acknowledgement, or it is not signed for any other reason, state the reason:

__________________________________________________________________________________________________ Describe the steps taken to obtain the Patient’s (or personal reps) signature on the Acknowledgement:

_________________________________________________________________________________________________________________________________

Signature of Practice Representative: ___________________________________________________ Date: ___________

Patient Account #:______________________________________ PF-17 Rev. 10/19

______________________________ (Contact Number)

_______________ (Date)

Patient Communication/Appt. Cancellation Policy/Rx History

PF-45 Rev. 9/18

Patient Name: _____________________________________________ DOB: _____________

Patient Communication OptionsAtlanta Allergy & Asthma (AAA) offers several options to receive practice communications such as

appointment confirmations/reminders, clinical care reminders, and occasional practice updates such as office

moves or weather closings. These notifications are in addition to the messages you receive through your

Patient Portal. If you have not activated your portal account, please call 770 953-3331 or provide your email

address below. Our staff will assist you with activation.

Check your preferred option(s) for receiving notifications. You may choose voice, text, OR email - or anycombination of the three.

Voice Message: Best Phone Number: _________________________________________

Time of day for phone call reminder ___AM (9a-12p) ___Noon (12p-3p) ___PM (3p-8p)

Text message: Cell Phone # _______________________________________

Email: Email Address: ___________________________________________

Appointment Cancellation Policy:______ Your appointment is important to both you and the Atlanta Allergy & Asthma staff.

Patient/ If you cannot keep your appointment for any reason, please contact us at least 24 hours priorGuardian to your scheduled appointment time. If you do not keep your appointment, or cancel withoutInitial a 24-hour notice, you may be charged a $25 no-show fee.

Consent to Obtain External Prescription HistoryIn order to provide the highest standard of care, it is necessary for our physicians to know your prescription medication history. Our electronic health record system will allow us to view your current and past medications which can prevent negative interactions between drugs.

____ I Authorize AAA and its Affiliated Providers to view my external prescription history via our electronichealth record system, eClinicalWorks. My prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my providers and authorized staff of AAA, and it may include prescriptions going back a number of years.

____ I DO NOT Authorize AAA and its Affiliated Providers to view my external prescription history via ourelectronic health record system, eClinicalWorks.

I understand I can change my authorization by completing a new form at any time and the change will be effective when the new form is received by Atlanta Allergy & Asthma, P.A.

__________________________________________ ________________________________ ____________(Signature of patient/authorized representative) (Print name if other than patient) (Date)

Marketing and Referral Questionnaire

Thank you for choosing Atlanta Allergy & Asthma. Please take a moment and let us know how you heard about our practice.

PATIENT NAME: APPT DATE:

How did you hear about our practice? (Please indicate ALL that apply)

Your Physician: (NAME)

Insurance Co. Booklet/Website: (PLAN)

Atlanta Allergy & Asthma Employee: (NAME)

Friend/Family Member: (NAME)

Check ALL that apply:

AAA Website Outdoor Billboards

Google WSB AM Radio/Scott Slade

Other Search Engine (Yahoo/Bing) Local News (Radio/TV/Print)

Yelp Social Media (Facebook/Twitter)

HealthGrades.com Health Fair/Community Event

Vitals.com Urgent Care/Pharmacy-based Clinics

Yellow Pages Other: ______________________

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Staff:

ACCOUNT NUMBER: OFFICE LOCATION:

PF-35 Rev. 3/18

Allergy Skin Test Information

Important Information for your Allergy Skin Test Appointment:

o It is very important to be on time for your skin test appointment. If you arrive late,we may be unable to test you due to time constraints.

o Allow 2-3 hours for skin testing. You will discuss the results with your doctor afterthe skin test.

o Wear comfortable clothing. You will be asked to take your top off, so do not wear aone-piece outfit.

o Skin testing is a simple series of tiny scratches made on your back with aninstrument that has small toothpick-like prongs each containing trace amounts of asingle allergen. Your doctor determines the number of tests done according to thehistory you have given. Skin testing is not painful but can be somewhatuncomfortable. Some describe the prick test sensation as being “like a cat walkingover the back.”

o After skin prick testing some patients may also receive intradermal testing. Withintradermal tests, a small amount of the allergen is injected under the skin of thearm to see if it causes a reaction. This test feels like pinches.

o Swelling or redness at the skin test sites, which may appear several hours afteryour testing, are called "delayed reactions" and do not have any significance. Anyitching associated with these reactions can be managed with steroid creams andantihistamines. This may persist for several days.

o It is important to stay off antihistamines for seven (7) days prior to testing.Antihistamines will block the skin test reaction. (See detailed list of medicationsincluded in New Patient Packet and on our website.)

o It is recommended you eat prior to skin testing.

Allergy Skin Testing – Medication List

Important Information about Allergy Skin Testing:

Patients scheduled for allergy skin testing must stop taking any medications that contain antihistamines as they will affect the results of your test. This includes both over-the-counter as well as prescription medications. Do not discontinue antidepressants/psychotropic medications or any other medications without consulting with your prescribing physician. Call your pharmacy or prescribing physician if you are unsure about the names of your medications. Asthma medications do not affect skin testing. Do not stop your asthma medications.

The following is a list of medications that must be STOPPED SEVEN (7) DAYS before skin testing: Actifed Adapin Advil Allergy Advil PM Alavert Allegra Allerhist Allertan Amitriptyline Anafranil Antivert Asendin Ataraz Atrohist Aventyl BC Cold Benadryl Bentyl Benztropin Biohist Bonine Brompheniramine Carbinoxamine Cetirizine Chlortrimeton

Clarinex Claritin Clemastine Clomipramine Cogentin Comtrex Contac Coricidin Cyproheptadine Desipramine Dimetapp Diphenhydramine Doxepin Dramamine Drixoral Durahist Duratan Dytan Elavil Etrafon Excedrin PM Fexofenadine Hydroxyzine Imipramine Limbitrolr

Loratadine Ludiomil Levocetirizine Marezine Meclizine Norpramin Nortriptyline Nyquil Pamelor Pediacare Pediatan Periactin Phenergan Polyhistine Promethazine Protriptyline Pyribenzamine Remeron Resperidone Risperdal Robitussin Cough, Cold & Allergy Rynatan Ryneze Semprex

Seroquel Sinequan Singlet Sominex Sudafed Cold & Allergy Surmontil Tacaryl Tandur Tavist Temaril Theraflu Tofranil Triaminic Triavil Trimipramine Trinalin Tylenol Allergy Tylenol Cold Tylenol PM Unisom Vicks Vivactil Xyzal Zonolon Zyrtec

Note: This list includes the most common antihistamines; however there may be some not listed here. Any over- the-counter medications with the word “Allergy”, most over-the-counter cough and cold medications, and over- the-counter sleep medications may affect testing and should be stopped prior to your appointment. If you have any questions, please call us at 770.953.3331.

The following medications must be STOPPED TWO (2) DAYS before skin testing: GI MEDICATIONS (for reflux and indigestion) Axid Cimetidine

Famotidine Nizatidine

Pepcid Ranitidine

Tagamet Zantac

ANTIHISTAMINE NASAL SPRAYS Azelastine Astelin

Astepro Patanase

Dymista